Knowledge, attitudes, practices and acceptability of a school preventive chemotherapy programme for schistosomiasis and soil-transmitted helminths control in Angola

Abstract

Schistosomiasis and soil-transmitted helminth (STH) control programs require target population engagement, assessed through knowledge, attitudes and practices (KAP) surveys. We report the results of a KAP survey of Angolan schoolchildren supported by a school preventive chemotherapy (PC) programme, without or with a school water, sanitation and hygiene (WASH) programme (PC+/WASH− and PC+/WASH+, respectively); and schoolchildren without a school PC or WASH program (PC−/WASH−). Schoolchildren from PC+/WASH− (N = 218), PC+/WASH+ (N = 250) and PC−/WASH− (N = 254) schools were interviewed. Descriptive statistics were used to report demographics and survey responses. Chi-square or Fisher's exact test was used to compare PC+/WASH− schoolchildren with (i) PC+/WASH+ and (ii) PC−/WASH− schoolchildren. A lower proportion of PC+/WASH− schoolchildren used latrines and a higher proportion practised open defecation at school compared with PC+/WASH+ schoolchildren. A lower proportion of PC+/WASH− schoolchildren always washed their hands after toileting and before meals at school compared with PC+/WASH+ schoolchildren. However, the PC+/WASH− schoolchildren reported better toileting and handwashing practices at school compared to PC−/WASH− schoolchildren. Over 90% of PC+ schoolchildren agreed with schistosomiasis and STH control and accepted schoolteacher PC delivery. Expanding the integration of both school PC and WASH programs will improve health behaviours relevant to reduce the risk of schistosomiasis and STHs in schoolchildren.

This article is part of the theme issue ‘Challenges and opportunities in the fight against neglected tropical diseases: a decade from the London Declaration on NTDs’.

1. Background

Schistosomiasis and soil-transmitted helminth (STH) infections are major contributors to the burden of disease caused by neglected tropical diseases (NTDs) and have been targeted by the World Health Organization (WHO) for elimination as a public health problem by 2030 [1,2]. These parasitic infections cause a range of gastrointestinal and urogenital diseases, with children particularly vulnerable to more severe complications from infection including anaemia, malnutrition, and impaired growth and development [1]. An integral control strategy for schistosomiasis and STH infections is regular delivery of preventive chemotherapy (PC) with anthelminthic medications, such as praziquantel for schistosomiasis and albendazole for STHs, usually targeting school-aged children [3]. To optimize the sustainable control of these infections, interventions to improve water, sanitation and hygiene (WASH) access and practices are important adjuncts to PC programmes [1]. Essential to the success of NTD control strategies is engagement with the target population through education on disease burden, transmission and prevention, coupled with understanding the awareness and acceptability by communities of the control strategies implemented and their preferences for ongoing control measures. Evaluation of these aspects of disease and control strategies in target populations is typically conducted through knowledge, attitudes and practices (KAP) surveys. However, despite school-aged children being a key target population for control measures, there are limited published contemporary data on KAP indicators focusing on these NTDs in exclusive school-aged cohorts [4–8].

Schistosomiasis and STH infections are long recognized public health problems in Angola [9,10]. The Angolan Ministry of Health, in conjunction with the MENTOR Initiative and the END Fund, initiated a school-based PC programme for the control of STH infections in 2013 and schistosomiasis in 2014 in Huambo, Uige and Zaire provinces. The programme was informed by a prevalence survey conducted in 2014, which estimated the prevalence of schistosomiasis across all three provinces as 31.4% (municipality range 5.9–77.3%) and the prevalence of STH infections as 29.5% (municipality range 0.8–89.7%) [11]. In addition to school-based PC, a WASH programme has also been implemented in a subset of schools from 2016. The WASH interventions included the provision of materials for building latrines and handwashing stations, handwashing education and establishing hygiene clubs.

To evaluate the impact of the school PC programme on the prevalence and intensity of schistosomiasis and STH infections, an impact assessment was performed in 2021 [12]. This impact assessment also incorporated a student KAP survey, which included an awareness and acceptability component. The aim of this analysis is to better understand student KAP regarding schistosomiasis and STH infections, transmission and control, as well as the awareness and acceptability of the school PC programme and preferences for future PC programmes. In addition, we investigate potential differences in KAP indicators for schoolchildren supported by a school PC program but not a WASH program (PC+/WASH−) versus schoolchildren who were supported by both school PC and WASH programs (PC+/WASH+) and schoolchildren who were not supported by either a school PC or WASH program (PC−/WASH−).

2. Methods

The impact assessment of the 2014–2020 school PC program for schistosomiasis and STHs control across Huambo, Uige and Zaire provinces took place between May and August 2021, with full details reported elsewhere [12]. The student KAP survey included two groups of primary school-aged children across Huambo, Uige and Zaire provinces: those from PC+/WASH− schools and those from PC+/WASH+ schools. A third group of schoolchildren from PC−/WASH− schools in Kwanza Norte province were also surveyed as an additional comparator with schoolchildren from PC+/WASH− schools to account for any influences the PC program might have on KAP indicators. Figure 1 displays the location of the Huambo, Uige, Zaire and Kwanza Norte provinces in Angola.

Figure 1.

Location of Huambo (blue), Uige (red), Zaire (orange) and Kwanza Norte (pink) provinces, Angola (green). Base-layer map provided by the Database of Global Administrative Areas (GADM): https://gadm.org/download_country.html; license: https://gadm.org/license.html.

The sample size was calculated using the Fleiss method with continuity correction factor for an unmatched case-control study through OpenEpi [13], with the following parameters: (i) expected proportion of the primary indicator (uses a latrine at school) for schoolchildren supported by the school WASH program of 70% (unpublished data from previous WASH surveys provided by The MENTOR Initiative); (ii) expected proportion of primary indicator (uses a latrine at school) for schoolchildren not supported by a school WASH program of 55% [4]; (iii) two-level confidence interval (CI) of 95%; and (iv) power of 90%. This resulted in a sample size calculation of 230 schoolchildren for each of the PC+/WASH− and PC+/WASH+ schools across Huambo, Uige and Zaire provinces [13]. For fieldwork feasibility we aimed to interview three to five schoolchildren from each school selected from Huambo, Uige and Zaire provinces. An additional sample of 230 schoolchildren from PC−/WASH− schools was selected in Kwanza Norte province (where there were no school PC or WASH programs in operation). Schools were selected via systematic random sampling from schools participating in the schistosomiasis impact assessment for Huambo, Uige and Zaire provinces (stratified by WASH status), and from a list of registered schools in Kwanza Norte provided by the Ministry of Health of Angola, using SAS version 9.4 [14]. Schoolchildren were selected through systematic random sampling from those invited to participate in the schistosomiasis parasitological survey (Huambo, Uige and Zaire provinces), or from those present on the day of field team arrival (Kwanza Norte province).

A 52-question face-to-face interview was conducted in Portuguese to assess: (i) knowledge of schistosomiasis and STHs, including symptoms, transmission, treatment and control; (ii) sanitation and hygiene practices at school; and (iii) awareness and acceptability of the PC program (see electronic supplementary material).

(a) . Data management and analysis

Each schoolchild was assigned a unique participant identification number (ID) that was entered onto paper registers with the participant's name, age and sex. Participant ID and responses to the KAP survey were entered directly into the ESPEN Collect mobile data collection tool (see https://espen.afro.who.int/tools-resources/espen-collect) using tablets. If tablets were not available or schools were not pre-entered into ESPEN Collect (due to school substitution following operational assessment), responses were recorded in paper forms and then entered into ESPEN Collect or transferred to the data management centre (Kirby Institute, UNSW Sydney, Australia). Data recorded in ESPEN Collect were made available to select members of the project team through a secure cloud-based data repository (https://metabase.espen.securedatakit.com).

Descriptive statistics were used to describe the number and proportion of schoolchildren who provided responses to individual questions in the survey. A χ² (when up to 20% of cells have an expected count of less than 5) or Fisher's exact test (when more than 20% of cells have an expected count of less than 5) was performed to assess for differences in indicators between schoolchildren who attended a PC+/WASH− school and (i) those who attended a PC+/WASH+ school and (ii) those who attended a PC−/WASH− school. All statistical analyses were performed using STATA version 17.0 (College Station, TX, USA).

3. Results

A total of 722 schoolchildren participated in the KAP survey, with 218 (30.2%) schoolchildren from 42 PC+/WASH− schools, 250 (34.6%) schoolchildren from 47 PC+/WASH+ schools and 254 (35.2%) schoolchildren from 45 PC−/WASH− schools. Similar age, sex and setting characteristics were demonstrated between the PC+/WASH− and PC+/WASH+ groups (table 1). Only demographic data for sex were collected for the PC−/WASH− group, which was similar to the other two groups.

Table 1.

Demographic characteristics of schoolchildren participating in the knowledge, attitudes, practices and acceptability survey. Table data are given as ‘percentage of total number (total number, n)'. PC+/WASH−, PC supported/WASH unsupported; PC+/WASH+, PC supported/WASH supported; PC−/WASH−, PC unsupported/WASH unsupported; IQR, interquartile range; n.a., not available.

	PC+/WASH−	PC+/WASH+	PC−/WASH−
	N = 218	N = 250	N = 254
median age, years (IQR)	9.0 (8.6, 10)	9.0 (8.4, 9.2)	n.a.
sex
male	58.7 (128)	55.6 (139)	53.9 (137)
female	41.3 (90)	44.4 (111)	46.1 (117)
setting
rural	57.8 (128)	56.4 (141)	n.a.
urban	42.3 (90)	43.6 (109)	n.a.

(a) . Comparing schoolchildren supported by a school PC program without and with a school WASH program

When comparing schoolchildren from PC+/WASH− and PC+/WASH+ schools there were differences in household water source, with a lower proportion of children attending PC+/WASH− schools reporting their household water source as a protected well or pit (11.0% versus 30.4%, p < 0.001) and a higher proportion reporting their household water source as an unprotected well or pit (32.1% versus 5.6%, p < 0.001) (table 2). A lower proportion of schoolchildren from PC+/WASH− schools used a pit latrine at school (37.6% versus 60.8%, p < 0.001) and a higher proportion practised open defecation (47.3% versus 18.0%, p < 0.001) compared with schoolchildren from PC+/WASH+ schools (table 2). Comparison of household defecation practices could not be evaluated due to the high proportion of no responses. Schoolchildren from PC+/WASH− schools reported poorer hygiene at school compared to schoolchildren from PC+/WASH+ schools, with a lower proportion of schoolchildren always washing their hands after toileting (49.5% versus 66.0%, p < 0.001) and before meals (44.0% versus 61.4%, p = 0.003), and a lower proportion using water and soap to wash hands at school (77.1% versus 90.0%, p < 0.001) (table 2). A similar trend was found in the household, with schoolchildren from PC+/WASH− schools reporting poorer toileting and handwashing practices compared to those from PC+/WASH+ schools (table 2).

Table 2.

Responses to water, sanitation and hygiene indicators for the PC supported/WASH unsupported (PC+/WASH−), PC supported/WASH supported (PC+/WASH+) and PC unsupported/WASH unsupported (PC−/WASH−) school groups. Table data are given as ‘percentage of total number (total number, n)'. Data in italics indicate statistically significant p-values of <0.05. PC, preventive chemotherapy; WASH, water, sanitation and hygiene.

	Huambo, Uige and Zaire Provinces				Kwanza Norte Province
	total	PC+/WASH−	PC+/WASH+	p-valuea	PC−/WASH−	p-valueb
	N = 468	N = 218	N = 250		N = 254
water source (household)
no water source	2.8 (13)	3.2 (7)	2.4 (6)	0.59	0 (0)	0.004
tap water (source in house)	4.1 (19)	6.0 (13)	2.4 (6)	0.05	11.4 (29)	0.04
tap water (source out of house)	8.1 (38)	6.9 (15)	9.2 (23)	0.36	41.3 (105)	<0.001
protected well/pit	21.4 (100)	11.0 (24)	30.4 (76)	<0.001	0 (0)	<0.001
unprotected well/pit	23.3 (109)	32.1 (70)	15.6 (39)	<0.001	6.3 (16)	<0.001
pump hole	1.1 (5)	2.3 (5)	0 (0)	0.02	0 (0)	0.02
tanker truck	0.2 (1)	0.5 (1)	0 (0)	0.47	4.3 (11)	0.01
protected spring	1.9 (9)	0 (0)	3.6 (9)	0.004	3.2 (8)	0.01
unprotected spring	4.5 (21)	7.3 (16)	2.0 (5)	0.005	0 (0)	<0.001
surface water	29.9 (140)	28.0 (61)	31.6 (79)	0.39	33.1 (84)	0.23
other	1.7 (8)	2.3 (5)	1.2 (3)	0.48	0.4 (1)	0.10
defecation place (household)
flush toilet	6.4 (30)	2.3 (5)	10.0 (25)	0.001	1.6 (4)	0.74
pit latrine	38.7 (181)	21.6 (47)	53.6 (134)	<0.001	38.2 (97)	<0.001
composting toilet	6.2 (29)	10.1 (22)	2.8 (7)	0.001	17.3 (44)	0.030
open defecation	21.0 (98)	18.8 (41)	22.8 (57)	0.29	40.2 (102)	<0.001
other	3.2 (15)	2.8 (6)	3.6 (9)	0.60	2.0 (5)	0.76
no reply	24.4 (114)	44.5 (97)	6.8 (17)	<0.001	0 (0)	<0.001
defecation place (school)
flush toilet	5.8 (27)	2.8 (6)	8.4 (21)	0.009	3.9 (10)	0.48
pit latrine	50.0 (234)	37.6 (82)	60.8 (152)	<0.001	12.6 (32)	<0.001
composting toilet	4.5 (21)	5.5 (12)	3.6 (9)	0.32	26.8 (68)	<0.001
open defecation	31.6 (148)	47.3 (103)	18.0 (45)	<0.001	46.1 (117)	0.80
other	5.3 (25)	4.1 (9)	6.4 (16)	0.28	4.3 (11)	0.91
no reply	2.1 (10)	2.8 (6)	1.6 (4)	0.53	2.4 (6)	0.79
handwashing after toileting (household)				0.02		0.29
always	55.8 (261)	49.1 (107)	61.6 (154)		53.9 (137)
sometimes	35.9 (168)	39.9 (87)	32.4 (81)		36.2 (92)
rarely	4.1 (19)	5.5 (12)	2.8 (7)		7.5 (19)
never	2.1 (10)	1.8 (4)	2.4 (6)		0.4 (1)
no reply	2.1 (10)	3.7 (8)	0.8 (2)		2.0 (5)
handwashing after toileting (school)				<0.001		<0.001
always	58.3 (273)	49.5 (108)	66.0 (165)		44.1 (112)
sometimes	32.3 (151)	38.5 (84)	26.8 (67)		28.7 (73)
rarely	4.1 (19)	5.5 (12)	2.8 (7)		15.4 (39)
never	3.0 (14)	5.1 (11)	1.2 (3)		6.3 (16)
no reply	2.4 (11)	1.4 (3)	3.2 (8)		5.5 (14)
handwashing before meals (household)				<0.001		0.06
always	66.5 (311)	51.8 (113)	79.2 (198)		60.6 (154)
sometimes	27.8 (130)	39.0 (85)	18.0 (45)		30.3 (77)
rarely	2.6 (12)	5.1 (11)	0.4 (1)		7.5 (19)
never	1.1 (5)	2.3 (5)	0 (0)		0.4 (1)
no reply	2.1 (10)	1.8 (4)	2.4 (6)		1.2 (3)
handwashing before meals (school)				0.003		<0.001
always	53.4 (250)	44.0 (96)	61.6 (154)		28.0 (71)
sometimes	30.1 (141)	36.2 (79)	24.8 (62)		40.9 (104)
rarely	4.9 (23)	5.5 (12)	4.4 (11)		17.7 (45)
never	8.1 (38)	11.0 (24)	5.6 (14)		6.7 (17)
no reply	3.4 (16)	3.2 (7)	3.6 (9)		6.7 (17)
handwashing materials (household)				0.01		0.048
water only	11.5 (54)	15.6 (34)	8.0 (20)		8.7 (22)
water and soap	86.2 (403)	83.0 (181)	88.8 (222)		90.6 (230)
ash	0.2 (1)	0 (0)	0.4 (1)		0 (0)
other	0.6 (3)	0.9 (2)	0.4 (1)		0.4 (1)
no reply	1.5 (7)	0.5 (1)	2.4 (6)		0.4 (1)
handwashing materials (school)				<0.001		<0.001
water only	7.3 (34)	11.9 (26)	3.2 (8)		31.1 (79)
water and soap	84.0 (393)	77.1 (168)	90.0 (225)		50.4 (128)
ash	0 (0)	(0)	0 (0)		0 (0)
other	1.1 (5)	1.8 (4)	0.4 (1)		9.8 (25)
no reply	7.7 (36)	9.2 (20)	6.4 (16)		8.7 (22)
wears shoes outside				0.002		0.003
always	51.3 (240)	54.6 (119)	48.4 (121)		56.3 (143)
sometimes	34.2 (160)	33.9 (74)	34.4 (86)		40.6 (103)
rarely	5.8 (27)	4.1 (9)	7.2 (18)		2.4 (6)
never	6.6 (31)	3.2 (7)	9.6 (24)		0 (0)
no reply	2.1 (10)	4.1 (9)	0.4 (1)		0.8 (2)
wears shoes while defecating				<0.001		<0.001
always	54.9 (257)	58.7 (128)	51.6 (129)		74.8 (190)
sometimes	31.8 (149)	32.1 (70)	31.6 (79)		23.6 (60)
rarely	2.4 (11)	3.2 (7)	1.6 (4)		1.2 (3)
never	9.4 (44)	2.8 (6)	15.2 (38)		0 (0)
no reply	1.5 (7)	3.2 (7)	0 (0)		0.4 (1)

^aChi-square or Fishers exact test performed to compare indicators between schoolchildren from PC+/WASH− and PC+/WASH+ schools in Huambo, Uige and Zaire.

^bChi-square or Fishers exact test performed to compare indicators between schoolchildren from PC+/WASH− schools in Huambo, Uige and Zaire and schoolchildren from PC−/WASH− schools in Kwanze Norte.

Approximately 80% of students reported knowing about STH infections from both PC+/WASH− and PC+/WASH+ schools, with school being the most reported source of knowledge (61.9% for schoolchildren from PC+/WASH− schools and 53.2% for schoolchildren from PC+/WASH+ schools; table 3). Knowledge of schistosomiasis was under 50% in schoolchildren from both PC+/WASH− and PC+/WASH+ schools (table 3).

Table 3.

Responses to soil-transmitted helminth infection and schistosomiasis knowledge indicators for the PC supported/WASH unsupported (PC+/WASH−), PC supported/WASH supported (PC+/WASH+) and PC unsupported/WASH unsupported (PC−/WASH−) school groups. Table data are given as ‘percentage of total number (total number, n)'. Data in italics indicate statistically significant p-values of <0.05. PC, preventive chemotherapy; SCH, schistosomiasis; STH, soil-transmitted helminth; WASH, water, sanitation and hygiene.

	Huambo, Uige and Zaire Provinces				Kwanza Norte Province
	total	PC+/WASH−	PC+/WASH−	p-valuea	PC−/WASH−	p-valueb
	N = 468	N = 218	N = 250		N = 254
knowledge of STH infection				0.44		<0.001
yes	83.6 (391)	82.1 (179)	84.8 (212)		93.3 (237)
no	14.5 (68)	15.1 (33)	14.0 (35)		4.7 (12)
no reply	1.9 (9)	2.8 (6)	1.2 (3)		2.0 (5)
previously had STH infection				0.007		<0.001
yes	59.4 (278)	53.2 (116)	64.8 (162)		85.8 (218)
no	34.8 (163)	38.1 (83)	32.0 (80)		10.2 (26)
no reply	5.8 (27)	8.7 (19)	3.2 (8)		3.9 (10)
source of knowledge about STH infection
school	57.3 (268)	61.9 (135)	53.2 (133)	0.06	18.1 (46)	<0.001
health unit	10.9 (51)	9.6 (21)	12.0 (30)	0.41	12.2 (31)	0.37
community health worker	0.6 (3)	0.5 (1)	0.8 (2)	1.0	0 (0)	0.46
family member	20.1 (94)	21.6 (47)	18.8 (47)	0.46	72.1 (183)	<0.001
television	0.2 (1)	0.5 (1)	0 (0)	0.5	4.3 (11)	0.01
print media	0.4 (2)	0 (0)	0.8 (2)	0.50	0.4 (1)	1.0
friend	0.4 (2)	0.5 (1)	0.4 (1)	1.0	4.3 (11)	0.01
other	0.6 (3)	0.5 (1)	0.8 (2)	1.0	3.9 (10)	0.01
no reply	31.2 (146)	30.7 (67)	31.6 (79)	0.84	7.9 (20)	<0.001
treatment of STH infection
cannot be treated	0.6 (3)	0 (0)	1.2 (3)	0.25	1.6 (4)	0.12
medications from pharmacy/health centre	56.2 (263)	57.3 (125)	55.2 (138)	0.64	32.3 (82)	<0.001
traditional medicine	5.6 (26)	5.1 (11)	6.0 (15)	0.65	0 (0)	<0.001
other	1.3 (6)	0.9 (2)	1.6 (4)	0.69	0 (0)	0.21
no reply	38.5 (180)	39.5 (86)	37.6 (94)	0.68	66.1 (168)	<0.001
knowledge of SCH infection				0.008		0.06
yes	45.9 (215)	47.3 (103)	44.8 (112)		36.6 (93)
no	50.0 (234)	45.9 (100)	53.6 (134)		55.5 (141)
no reply	4.1 (19)	6.9 (15)	1.6 (4)		7.9 (20)
previously had SCH infection				0.16		<0.001
yes	15.8 (74)	19.3 (42)	12.8 (32)		12.6 (32)
no	32.5 (152)	31.7 (69)	33.2 (83)		49.2 (125)
no reply	51.7 (242)	49.1 (107)	54.0 (135)		38.2 (97)
source of knowledge about SCH infection
school	38.9 (182)	44.0 (96)	34.4 (86)	0.03	7.5 (19)	<0.001
health unit	4.9 (23)	3.7 (8)	6.0 (15)	0.25	5.5 (14)	0.34
community health worker	0.2 (1)	0.5 (1)	0 (0)	0.47	0 (0)	0.46
television	0 (0)	0 (0)	0 (0)	—	2.4 (6)	0.03
family member	10.7 (50)	8.7 (19)	12.4 (31)	0.20	26.4 (67)	<0.001
friend	0.4 (2)	0.5 (1)	0.4 (1)	1.0	5.5 (14)	0.001
other	0.2 (1)	0 (0)	0.4 (1)	1.0	5.5 (14)	<0.001
no reply	53.9 (252)	51.8 (113)	55.6 (139)	0.42	56.7 (144)	0.29
treatment of SCH infection
cannot be treated	0.4 (2)	0 (0)	0.8 (2)	0.50	0 (0)	—
medications from pharmacy/health centre	16.5 (77)	14.2 (31)	18.4 (46)	0.22	2.4 (6)	<0.001
traditional medicine	4.5 (21)	0.9 (2)	7.6 (19)	<0.001	0 (0)	0.21
mass drug administration	19.0 (89)	22.5 (49)	16.0 (40)	0.08	3.2 (8)	<0.001
no reply	63.9 (299)	61.9 (135)	65.6 (164)	0.41	91.7 (233)	<0.001

^aChi-square or Fishers exact test performed to compare indicators between schoolchildren from PC+/WASH− and PC+/WASH− schools in Huambo, Uige and Zaire.

^bChi-square or Fishers exact test performed to compare indicators between schoolchildren from PC+/WASH− schools in Huambo, Uige and Zaire and schoolchildren from PC−/WASH− schools in Kwanze Norte.

Across both groups supported by the school PC program, a higher proportion of schoolchildren reported the purpose of the school PC program to be for the control of STH infections compared to schistosomiasis (72.9% versus 31.2%; table 4). More than 90% of schoolchildren reported having taken PC in the previous year, which was easy to take for most (table 4). Notably, a higher proportion of schoolchildren from PC+/WASH− schools reported a side effect to the schistosomiasis medication compared with schoolchildren from PC+/WASH+ schools (21.8% versus 4.3%, p < 0.001), with a similar proportion of around 20% reporting a side effect to the STH medication across the two groups (table 4). Across both PC+/WASH− and PC+/WASH+ school groups, more than 90% of schoolchildren agreed with the need to control schistosomiasis and STH infections (table 4). Furthermore, approximately 90% of schoolchildren were happy with the delivery of PC at school and teachers delivering the medications (table 4).

Table 4.

Responses to the acceptability indicators for the PC supported/WASH unsupported (PC+/WASH−), PC supported/WASH supported (PC+/WASH+) and PC unsupported/WASH unsupported (PC−/WASH−) school groups. Table data are given as ‘percentage of total number (total number, n)'. Data in italics indicate statistically significant p-values of <0.05. PC, preventive chemotherapy; SCH, schistosomiasis; STH, soil-transmitted helminth; WASH, water, sanitation and hygiene.

	Huambo, Uige and Zaire Provinces				Kwanza Norte Province
	total	PC+/WASH−	PC+/WASH+	p-valuea	PC−/WASH−	p-valueb
	N = 468	N = 218	N = 250		N = 254
purpose of school PC
control STH infection	72.9 (341)	67.9 (148)	77.2 (193)	0.02	n.a.
control schistosomiasis	31.2 (146)	40.8 (89)	22.8 (57)	<0.001	n.a.
other	2.4 (11)	2.3 (5)	2.4 (6)	0.94	n.a.
no reply	16.9 (79)	17.0 (37)	16.8 (42)	1.0	n.a.
took PC at school last year				0.13
yes	94.2 (441)	94.5 (206)	94.0 (235)		n.a.
no	3.6 (17)	2.3 (5)	4.8 (12)		n.a.
no reply	2.1 (10)	3.2 (7)	1.2 (3)		n.a.
reason for taking PC	N = 441	N = 206	N = 235
had SCH/STH infection	24.7 (109)	25.7 (53)	23.8 (56)	0.65	n.a.
could have SCH/STH infection	18.6 (82)	23.8 (49)	14.0 (33)	0.009	n.a.
avoid SCH/STH infection	47.2 (208)	44.7 (92)	49.4 (116)	0.32	n.a.
treatment of stomach disease	0.2 (1)	0.5 (1)	0 (0)	0.47	n.a.
treatment of urinary disease	0.5 (2)	0 (0)	0.9 (2)	0.50	n.a.
others took it	0.5 (2)	0.5 (1)	0.4 (1)	1.0	n.a.
forced by teacher	0.2 (1)	0.5 (1)	0 (0)	0.47	n.a.
offered for free	0.9 (4)	1.5 (3)	0.4 (1)	0.34	n.a.
other	3.6 (16)	2.4 (5)	4.7 (11)	0.31	n.a.
no reply	11.8 (52)	11.2 (23)	12.3 (29)	0.70	n.a.
easy to take medicine	N = 441	N = 206	N = 235	0.47
yes	88.4 (390)	87.4 (180)	89.4 (210)		n.a.
no	9.5 (42)	9.7 (20)	9.4 (22)		n.a.
no reply	2.0 (9)	2.9 (6)	1.3 (3)		n.a.
side effects to medicine	N = 441	N = 206	N = 235
yes, to STH medicine	20.0 (88)	21.4 (44)	18.7 (44)	0.49	n.a.
yes, to SCH medicine	12.5 (55)	21.8 (45)	4.3 (10)	<0.001	n.a.
yes, but not sure which medicine	3.9 (17)	3.4 (7)	4.3 (10)	0.64	n.a.
none	59.4 (262)	56.3 (116)	62.1 (146)	0.22	n.a.
no reply	10.9 (48)	10.2 (21)	11.5 (27)	0.66	n.a.
specific side effect to medicine	N = 132	N = 70	N = 62
stomachache	8.3 (11)	5.7 (4)	11.3 (7)	0.35	n.a.
nausea/vomiting	37.9 (50)	50.0 (35)	24.2 (15)	0.002	n.a.
dizziness	41.7 (55)	54.3 (38)	27.4 (17)	0.002	n.a.
headache	15.9 (21)	15.7 (11)	16.1 (10)	0.95	n.a.
fever	3.0 (4)	1.4 (1)	4.8 (3)	0.34	n.a.
other	9.1 (12)	7.1 (5)	11.3 (7)	0.55	n.a.
no reply	8.3 (11)	8.6 (6)	8.1 (5)	0.92	n.a.
treatment for side effects	N = 132	N = 70	N = 62
no treatment	64.4 (85)	67.1 (47)	61.3 (38)	0.48	n.a.
medicine from health facility	16.7 (22)	11.4 (8)	22.6 (14)	0.09	n.a.
traditional medicine	0.8 (1)	0 (0)	1.6 (1)	0.47	n.a.
other	5.3 (7)	7.1 (5)	3.2 (2)	0.45	n.a.
no reply	11.4 (15)	11.4 (8)	11.3 (7)	0.98	n.a.
why did not take medicines	N = 17	N = 5	N = 12
was not sick	17.7 (3)	40.0 (2)	8.3 (1)	0.19	n.a.
was not at school	41.2 (7)	20.0 (1)	50.0 (6)	0.34	n.a.
worried about side effects	0 (0)	0 (0)	0 (0)	—	n.a.
did not like distributor	0 (0)	0 (0)	0 (0)	—	n.a.
other	5.9 (1)	0 (0)	8.3 (1)	1.0	n.a.
no reply	41.2 (7)	60.0 (3)	33.3 (4)	0.60	n.a.
agree with need to control STH infection				0.87		<0.001
yes	94.0 (440)	93.6 (204)	94.4 (236)		18.1 (46)
no	2.8 (13)	3.2 (7)	2.4 (6)		2.8 (7)
no reply	3.2 (15)	3.2 (7)	3.2 (8)		79.1 (201)
agree with need to control SCH infection				0.64		<0.001
yes	93.4 (437)	94.5 (206)	92.4 (231)		13.4 (34)
no	2.6 (12)	2.3 (5)	2.8 (7)		2.0 (5)
no reply	4.1 (19)	3.2 (7)	4.8 (12)		84.7 (215)
willing to take STH medicine in future				<0.001		<0.001
yes	60.9 (285)	46.8 (102)	73.2 (183)		0 (0)
no	0.9 (4)	0 (0)	1.6 (4)		0 (0)
no reply	38.3 (179)	53.2 (116)	25.3 (63)		100 (254)
reason for willingness to take STH in future	N = 285	N = 102	N = 183		N = 0
to treat STH infection	42.8 (122)	50.0 (51)	38.8 (71)	0.07	0 (0)	—
to prevent STH infection	34.7 (99)	40.2 (41)	31.7 (58)	0.15	0 (0)	—
because others take it	1.4 (4)	2.0 (2)	1.1 (2)	0.62	0 (0)	—
offered free	0.4 (1)	0 (0)	0.6 (1)	1.0	0 (0)	—
do not know	2.5 (7)	2.9 (3)	2.2 (4)	0.70	0 (0)	—
other	26.3 (75)	27.5 (28)	25.7 (47)	0.75	0 (0)	—
no reply	12.6 (36)	10.8 (11)	13.7 (25)	0.48	0 (0)	—
reason for not willing to take STH medicine future	N = 4	N = 0	N = 4		N = 0
not sick	0 (0)	0 (0)	0 (0)	—	0 (0)	—
worried about side effects	0 (0)	0 (0)	0 (0)	—	0 (0)	—
worried about pill taste/size	0 (0)	0 (0)	0 (0)	—	0 (0)	—
family refusal	0 (0)	0 (0)	0 (0)	—	0 (0)	—
do not want to take	0 (0)	0 (0)	0 (0)	—	0 (0)	—
do not know	0 (0)	0 (0)	0 (0)	—	0 (0)	—
other	75.0 (3)	0 (0)	75.0 (3)	—	0 (0)	—
no reply	25.0 (1)	0 (0)	25.0 (1)	—	0 (0)	—
preference for delivery of STH medicine in future
school	70.1 (328)	52.8 (115)	85.2 (213)	<0.001	78.0 (198)	<0.001
central point in village	1.1 (5)	0.5 (1)	1.6 (4)	0.38	17.3 (44)	<0.001
sanitary unit	10.3 (48)	7.8 (17)	12.4 (31)	0.10	27.2 (69)	<0.001
other	1.7 (8)	0.9 (2)	2.4 (6)	0.29	19.3 (49)	<0.001
no reply	25.9 (121)	44.5 (97)	0.6 (24)	<0.001	5.9 (15)	<0.001
willing to take SCH medicine in future				0.005		<0.001
yes	79.9 (374)	74.3 (162)	84.8 (212)		22.1 (56)
no	2.8 (13)	2.3 (5)	3.2 (8)		1.2 (3)
no reply	17.3 (81)	23.4 (51)	12.0 (30)		76.8 (195)
reason for willingness to take SCH medicine in future	N = 374	N = 162	N = 212		N = 56
treat SCH infection	42.5 (159)	56.2 (91)	32.1 (68)	<0.001	82.1 (46)	0.001
prevent SCH infection	67.4 (252)	72.2 (117)	63.7 (135)	0.08	82.1 (46)	0.14
offered free	2.4 (9)	3.7 (6)	1.4 (3)	0.18	0 (0)	0.34
because others took it	1.3 (5)	0.6 (1)	1.9 (4)	0.39	0 (0)	1.0
other	4.8 (18)	1.9 (3)	7.1 (15)	0.03	8.9 (5)	0.03
no reply	11.8 (44)	14.2 (23)	9.9 (21)	0.21	8.9 (5)	0.31
reason for not willing to take SCH medicine future	N = 13	N = 5	N = 8		N = 3
not sick	0 (0)	0 (0)	0 (0)	—	0 (0)	—
worried about side effects	0 (0)	0 (0)	0 (0)	—	0 (0)	—
worried about pill taste/size	0 (0)	0 (0)	0 (0)	—	0 (0)	—
family refusal	7.7 (1)	0 (0)	12.5 (1)	1.0	0 (0)	—
do not want to take	46.2 (6)	60.0 (3)	37.5 (3)	0.59	0 (0)	0.20
other	7.7 (1)	20.0 (1)	0 (0)	0.39	66.7 (2)	0.46
no reply	38.5 (5)	20.0 (1)	50.0 (4)	0.57	33.3 (1)	1.00
preference for delivery SCH medicine in future
school	84.8 (397)	85.8 (187)	84.0 (210)	0.59	0 (0)	—
central point in village	1.5 (7)	0.9 (2)	2.0 (5)	0.46	0 (0)	—
sanitary unit	10.5 (49)	11.0 (24)	10.0 (25)	0.72	0 (0)	—
do not know	1.7 (8)	2.3 (5)	1.2 (3)	0.48	0 (0)	—
other	2.1 (10)	2.8 (6)	1.6 (4)	0.53	0 (0)	—
no reply	9.4 (44)	7.8 (17)	10.8 (27)	0.34	100 (254)	<0.001
happy with delivery of PC at school				0.26		<0.001
yes	90.0 (421)	90.8 (198)	89.2 (223)		44.5 (113)
no	0.6 (3)	0 (0)	1.2 (3)		0 (0)
no reply	9.4 (44)	9.2 (20)	9.6 (24)		55.5 (141)
happy with teachers delivering PC				0.20		0.37
yes	91.5 (428)	93.6 (204)	89.6 (224)		95.3 (242)
no	1.7 (8)	1.8 (4)	1.6 (4)		0.4 (1)
no reply	6.8 (32)	4.6 (10)	8.8 (22)		4.3 (11)

^aChi-square or Fishers exact test performed to compare indicators between schoolchildren from PC+/WASH− and PC+/WASH− schools in Huambo, Uige and Zaire.

^bChi-square or Fishers exact test performed to compare indicators between schoolchildren from PC+/WASH− schools in Huambo, Uige and Zaire and schoolchildren from PC−/WASH− schools in Kwanze Norte.

(b) . Comparing schoolchildren supported by a school PC program without a WASH program and schoolchildren not supported by a school PC or WASH program

Comparison in survey responses between schoolchildren from PC+/WASH− schools across Huambo, Uige and Zaire and schoolchildren from PC-/WASH− schools in Kwanza Norte are also shown in tables 2, 3 and 4. Again, there were differences in the household water source, particularly with a lower proportion of children from PC+/WASH− schools reporting tap water (out of house source) as their household water source (6.9% versus 41.3%, p < 0.001) and a higher proportion reporting an unprotected well or pit as their household water source (32.1% versus 6.3%, p < 0.001) compared to children from PC−WASH− schools (table 2). A higher proportion of schoolchildren from PC+/WASH− schools used a pit latrine (37.6% versus 12.6%, p < 0.001) and a lower proportion used a composting toilet (5.5% versus 26.8%, p < 0.001) at school compared to those from a PC−/WASH− school (table 2). A similar proportion (approximately 45%) practised open defecation at school across the two groups (table 2). There were better hygiene practices among schoolchildren from PC+/WASH− schools compared to those from PC−WASH− schools. Most notably, a higher proportion of children from PC+/WASH− schools sometimes washed their hands (38.5% versus 28.7%, p < 0.001) and a lower proportion rarely washed their hands (5.5% versus 15.4%, p < 0.001) after toileting at school; and a higher proportion always washed their hand before meals at school (44.0% versus 28.0%, p < 0.001) (table 2). There was also a higher proportion of schoolchildren from PC+/WASH− schools that used water and soap at school compared to those from PC−/WASH− schools (77.1% versus 50.4%, p < 0.001; table 2).

A lower proportion of schoolchildren from PC+/WASH− schools reported knowledge of STH infection compared to those from PC−/WASH− schools (82.1% versus 93.3%, p < 0.001), but there was no statistically significant difference in the proportions of schoolchildren who reported knowledge of schistosomiasis across the two groups (36.6% versus 47.3%, p = 0.06; table 3). The main source of knowledge was school for children from a PC+/WASH− school, while a family member was the main source of knowledge for schoolchildren from a PC−/WASH− school (table 3). The high proportion of no responses limited comparison for many of the acceptability indicators between the two school groups, but both groups had more than 90% of schoolchildren happy with schoolteachers delivering PC (table 4).

4. Discussion

This analysis provides important insights into the knowledge, attitudes and practices regarding schistosomiasis and STH infections in a school-aged population in the context of school PC and WASH programs, with respect to school-attending children who have not been exposed to either of these interventions. This study demonstrates improved WASH-related behaviours for schoolchildren attending PC+/WASH+ schools compared to PC+/WASH− schools in three provinces where school-based PC for STH infections and schistosomiasis control has been in place since 2013 and 2014, respectively. The results in this paper demonstrate a positive impact of school WASH programs on WASH access and improved hygiene behaviour both at the school and household level, which ultimately will help to reduce schistosomiasis and STH transmission in Angola. This is in keeping with the increasing recognition of the role of integrating WASH interventions with PC programs as progressive steps towards accelerating and sustaining NTD control [15]. Interestingly, improved sanitation and hygiene behaviours were also seen among schoolchildren from PC+/WASH− schools compared to those from PC−/WASH− schools, which demonstrates that even treatment programs can have a beneficial impact on behaviour that reduces the risk of schistosomiasis and STH infections.

For the provinces of Huambo, Uige and Zaire, where the school PC program had been implemented, there was a high proportion of schoolchildren who reported knowledge of STH infection, but only a modest proportion of those reporting knowledge of schistosomiasis. This may reflect the difference in frequency of PC delivery, as this program had more frequent PC delivery for STH compared to schistosomiasis. This is supported by a higher proportion of schoolchildren reporting the purpose of the PC program being to control STH compared to schistosomiasis. Furthermore, similarities in the proportions of schoolchildren reporting STH and schistosomiasis knowledge across the PC+ school groups, irrespective of WASH status, suggests a greater role of the PC program in delivering health education in this setting. The level of schistosomiasis knowledge demonstrated in our school groups is lower than other KAP surveys conducted recently in school-aged children living in schistosomiasis-endemic regions of sub-Saharan Africa, either preceding or without an active PC program [4,5], although other KAP surveys indicate a similar level of schistosomiasis knowledge in school-aged children receiving school-based PC [8] and those without an active school PC program [6]. School was found to be the main source of knowledge for schistosomiasis and STH infection in schools from Huambo, Uige and Zaire, which likely reflects exposure to the long-running school PC program in these provinces, and this has been similarly demonstrated in other KAP surveys in school-aged children [4,8]. Interestingly, in Kwanza Norte province, where there have been no school-based control strategies for schistosomiasis or STH infections, there was a higher proportion of STH knowledge compared to the PC+/WASH− school group, but a similar proportion of schistosomiasis knowledge. To our knowledge there have been no school-based programs for STH or schistosomiasis control in Kwanza Norte, but we cannot exclude other community-based programs. The fact that the main source of knowledge reported by those who provided a response in Kwanza Norte was a family member is consistent with the lack of school control programs and suggests alternative sources of information that raise potential for misconceptions and diverging beliefs resulting from messaging from family members [16]. Our results support the role of school control programs in providing health education and WASH interventions, as they are likely to result in improved sanitation and hygiene practices in schoolchildren both at school and in the household. This is consistent with the recognized importance of schools as a source of health education [4,5], particularly in countries like Angola where primary school enrolment is mandatory.

Our findings demonstrated a high acceptability of the school PC program for school-attending children, with the majority reporting the PC as easy to take, agreeing with the need to control schistosomiasis and STH infections, and being supportive of PC delivery by teachers at school. There was also a high acceptance of school PC delivery for those attending school but not already engaged in a school PC program. This bodes well for the engagement of students in school-based PC programs, should they be continued or expanded in this setting.

The main limitation to this study is the amount of 'no responses' for certain questions in the questionnaire, particularly from schoolchildren from Kwanza Norte. This may be in part due to the lack of engagement through school schistosomiasis and STH control programs in Kwanza Norte, and limits the ability to ascertain the relative contributions of the PC and school WASH programs in improving the KAP of schoolchildren toward controlling schistosomiasis and STH infections, and acceptability for ongoing control strategies. In addition, this study only interviewed school-attending children, which introduces a selection bias and limits the investigation of KAP indicators and the acceptability of a school PC program for the broader school-aged population.

5. Conclusion

This KAP survey provides unique insights from a school-aged population with different exposures to school PC and WASH programs. Schoolchildren from a school with a PC program but without a WASH program were found to have poorer sanitation, hygiene attitudes and practices compared to those from a school with both PC and WASH programs. However, those from schools with a PC program and without a WASH program were found to have better sanitation and hygiene behaviours compared with those from schools without a PC or WASH program. This not only provides the impetus for the expansion of the school WASH program, but also highlights the value of school PC programs in improving health behaviours for schistosomiasis and STH control beyond the administration of medications. Furthermore, there was a high agreement regarding the need for and acceptability of the school schistosomiasis and STH PC program by schoolchildren, indicating a high likelihood of engagement from this target population for both present and future PC program implementation.

Ethics

Approval for the survey protocol was obtained by the Ministry of Public Health of Angola (17/C.E./2021) and the University of New South Wales, Sydney, Australia (HC210192). Informed written consent was obtained from the school directors of each school to allow field teams to visit. Parents/guardians at the school were then provided with all the relevant study information and informed written consent was obtained from parents/guardians of schoolchildren present on the day when field teams visited to conduct the survey.

Data accessibility

Data are available from the Ministry of Health Institutional Data Access via geral@inis.gov.ao or from: https://www.inis.gov.ao/index.php/contactos.

The data are provided in electronic supplementary material [17].

Authors' contributions

A.W.B.: conceptualization, data curation, formal analysis, methodology, project administration, writing—original draft; E.P.M.: conceptualization, funding acquisition, investigation, methodology, resources, writing—review and editing; L.D.: conceptualization, methodology, project administration, writing—review and editing; L.B.P.: investigation, project administration, resources, writing—review and editing; L.M.M.L.: investigation, project administration, resources, writing—review and editing; A.D.: funding acquisition, methodology, project administration, resources, supervision, writing—reviewing and editing; P.N.M.: investigation, methodology, resources, software, writing—review and editing; P.E.: investigation, methodology, project administration, resources, supervision, writing—review and editing; S.L.: conceptualization, funding acquisition, methodology, project administration, resources, supervision, writing—review and editing; S.V.N.: conceptualization, funding acquisition, investigation, methodology, project administration, supervision, writing—review and editing.

All authors gave final approval for publication and agreed to be held accountable for the work performed therein.

Conflict of interest declaration

We declare we have no competing interests.

Funding

This study was funded by The END Fund. Additional resources were provided by the Ministry of Health of Angola and the Provisional Directorates in Angola.